Project Summary/Abstract Cardiovascular disease (CVD) causes 2,200 deaths in Americans every day. Yet effective implementation of evidence-based interventions that reduce CVD-related morbidity and mortality remains a substantial challenge. The Patient-Centered Medical Home including self-management, personalized health records, and team-based care is a strategy to improve care for patients with multiple chronic conditions. Building upon this framework, we developed an innovative team-based intervention, the Cardiovascular Risk Service (CVRS), which includes a centralized, pharmacist-led cardiovascular risk service and prevention services (e.g., vaccinations, cancer screenings) model to support primary care providers with CVD management and achievement of key performance measures. Results from one of our previous NIH-funded clustered-randomized trials showed a decrease in CVD risk factors in CVRS intervention patients receiving care through private physician offices. However, we discovered many more barriers to adoption of the CVRS in large health centers in another ongoing trial than the major positive support we received in small rural private clinics. Our long-term goal is to improve CVD management through team-based primary care. The application objective is to test the scalability of the CVRS in 12 large, organizationally and culturally diverse (diverse) hospitals and health- systems, many with high proportions of minority and underserved patients, using a pragmatic cluster- randomized design. Scaling-up the CVRS will require an assessment of adoption, implementation, and maintenance for broader dissemination and implementation. Our central hypothesis is that barriers and facilitators to CVRS implementation will vary across diverse primary care offices. We will use a transdisciplinary approach in collaboration with national experts in educational policy to measure these variances by means of mixed methods including interviews, observations, and surveys. The proposed study rationale is a novel implementation approach to improve CVD management and prevention services in patients with complex medical histories and will lead to innovative strategies for broader adoption by US health systems. Grounded in the RE-AIM framework, we will accomplish our objective and test our central hypothesis with these specific aims: Aim 1: Identify, understand, and develop strategies for overcoming barriers to the adoption, implementation, and maintenance of the CVRS in diverse primary care offices. Aim 2: Determine the real-world reach and effectiveness of the CVRS in diverse primary care offices. Aim 3: Determine CVRS sustainability and adaptation in diverse primary care offices. Our approach is innovative because it will ask: ?How can implementation processes be improved and maintained?? as well as ?Can implementation and maintenance be ?tailored? to real-world primary care providers so that they desire expansion to underserved patients?? This study design is novel because it will be the first to evaluate the adoption, implementation, and maintenance of a behavioral intervention using the comprehensive model in large, complex health systems.